Basic Information
| Provider Information | |||||||||
| NPI: | 1710290325 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KINEMATIC CONCEPTS PHYSICAL THERAPY & SPORTS REHAB, PLLC | ||||||||
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| OtherOrganizationName: | MOMENTUM PHYSICAL THERAPY & SPORTS REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8627 CINNAMON CREEK DR | ||||||||
| Address2: | SUITE 402 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782401480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106958731 | ||||||||
| FaxNumber: | 2105980432 | ||||||||
| Practice Location | |||||||||
| Address1: | 11219 POTRANCO RD | ||||||||
| Address2: | BUILDING A #110 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782535848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106796900 | ||||||||
| FaxNumber: | 2106796904 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2010 | ||||||||
| LastUpdateDate: | 11/27/2013 | ||||||||
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| AuthorizedOfficialLastName: | ELMS | ||||||||
| AuthorizedOfficialFirstName: | CHAD | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CHARIMAN OF THE BOARD | ||||||||
| AuthorizedOfficialTelephone: | 2103729600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0084HN | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |